Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

CM-SHARE: Development, Integration, and Adoption of an Electronic Health Record-Linked Digital Health Solution to Support Care for Diabetes in Primary Care

IN BRIEF Chronic conditions such as diabetes are largely managed by primary care providers (PCPs), with significant patient self-management. This article describes the development, pilot testing, and fine-tuning of a Web-based digital health solution to help PCPs manage patients with cardiometabolic diseases during routine office encounters. It shows that such products can be successfully integrated into primary care settings when they address important unmet needs and are developed with input from end-users.

Time Requirements of Paper-Based Clinical Workflows and After-Hours Documentation in a Multispecialty Academic Ophthalmology Practice

PURPOSE

To assess time requirements for patient encounters and estimate after-hours demands of paper-based clinical workflows in ophthalmology.

DESIGN

Time-and-motion study with a structured survey.

METHODS

This study was conducted in a single academic ophthalmology department. A convenience sample consisted of 7 attending ophthalmologists from 6 subspecialties observed during 414 patient encounters for the time-motion analysis and 12 attending ophthalmologists for the survey. Outcome measurements consisted of total time spent by attending ophthalmologists per patient and time spent on documentation, examination, and talking with patients. The survey assessed time requirements of documentation-related activities performed outside of scheduled clinic hours.

RESULTS

Among the 7 attending ophthalmologists observed (6 men and 1 woman), mean ± SD age 43.9 ± 7.1 years, during encounters with 414 patients (57.8 ± 24.6 years of age), total time spent per patient was 8.1 ± 4.8 minutes, with 2.8 ± 1.4 minutes (38%) for documentation, 1.2 ± 0.9 minutes (17%) for examination, and 3.3 ± 3.1 minutes (37%) for talking with patients. New patient evaluations required significantly more time than routine follow-up visits and postoperative visits. Higher clinical volumes were associated with less time per patient. Survey results indicated that paper-based documentation was associated with minimal after-hours work on weeknights and weekends.

CONCLUSIONS

Paper-based documentation takes up a substantial portion of the total time spent for patient care in outpatient ophthalmology clinics but is associated with minimal after-hours work. Understanding paper-based clinical workflows may help inform targeted strategies for improving electronic health record use in ophthalmology.

Six habits of highly successful health information technology: powerful strategies for design and implementation

Healthcare information technologies are now a routine component of patient-clinician interactions. Originally designed for operational functions including billing and regulatory compliance, these systems have had unintended consequences including increased exam room documentation, divided attention during the visit, and use of scribes to alleviate documentation burdens. In an age in which technology is ubiquitous in everyday life, we must re-envision healthcare technology to support both clinical operations and, above all, the patient-clinician relationship. We present 6 habits for designing user-centered health technologies: (1) put patient care first, (2) assemble a team with the right skills, (3) relentlessly ask WHY, (4) keep it simple, (5) be Darwinian, and (6) don't lose the forest for the trees. These habits should open dialogues between developers, implementers, end users, and stakeholders, as well as outline a path for better, more usable technology that puts patients and their clinicians back at the center of care.

Factors Associated With Electronic Health Record Usage Among Primary Care Physicians After Hours: Retrospective Cohort Study

Background

There is limited published data on variation in physician usage of electronic health records (EHRs), particularly after hours. Research in this area could provide insight into the effects of EHR-related workload on physicians.

Objective

This study sought to examine factors associated with after-hours EHR usage among primary care physicians.

Methods

Electronic health records usage information was collected from primary care pediatricians in a large United States hospital. Inclusion criteria consisted solely of being a primary care physician who started employment with the hospital before the study period, so all eligible primary care physicians were included without sampling. Mixed effects statistical modeling was used to investigate the effects of age, gender, workload, normal-hour usage, week to week variation, and provider-to-provider variation on the after-hour usage of EHRs.

Results

There were a total of 3498 weekly records obtained on 50 physicians, of whom 22% were male and 78% were female. Overall, more EHR usage during normal work hours was associated with decreased usage after hours. The more work relative value units generated by physicians, the more time they spent interacting with EHRs after hours (β=.04, P<.001) and overall (ie, during normal hours and after hours) (β=.24, P<.001). Gender was associated with total usage time, with females spending more time than males (P=.03). However, this association was not observed with after-hours EHR usage. provider-to-provider variation was the largest and most dominant source of variation in after-hour EHR usage, which accounted for 52% of variance of total EHR usage.

Conclusion

The present study found that there is a considerable amount of variability in EHR use among primary care physicians, which suggested that many factors influence after-hours EHR usage by physicians. However, provider-to-provider variation was the largest and most dominant source of variation in after-hours EHR usage. While the results are intuitive, future studies should consider the effect of EHR use variations on workload efficiency.

Nurse-led medicines' monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: An observational and interview study

Introduction

Preventable adverse effects of medicines often pass unnoticed, but lead to real harm.

Intervention

Nurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.

Objectives

This study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.

Methods

Administration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.

Results

Residents were aged 60–95, and prescribed 1–17 (median 9 [interquartile range (IQR) 7–13]) medicines. ADRe identified a median of 18 [IQR 11.5–23] problems per resident and nurses made 2 [1–2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors’ non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses’ concerns regarding residents’ welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.

Implications

To our knowledge, ADRe is the only instrument that brings a full account of patients’ problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.

Surgeon Burnout: Defining, Identifying, and Addressing the New Reality

Surgeon wellness is a multidimensional commitment that encompasses occupational, mental, physical, emotional, and social domains. Loss of professional control, autonomy, and flexibility; inefficient processes; disjointed workplace relationships and goals; excessive administrative burdens; poor work-life balance; and frustrations with medical record and order entry systems have all been associated with burnout. Described as a syndrome of emotional exhaustion, depersonalization, and loss of a sense of personal accomplishment, burnout can have myriad untoward consequences. The strong link between surgeons' personal and professional identities can lead to a perfect storm of burnout, depression, compromised patient safety and quality of care, physician job loss and career dissatisfaction, substance abuse, damage to personal relationships, and suicide. The alarming scope of this problem cannot be confined to a single specialty or practice setting and is expected to increase without much needed changes to surgeon work practices and work environments. A heightened focus on wellness in the workplace with attention to improving workflow, scheduling, collaboration, and resource allocation is a welcome step taken by several institutions and championed by professional societies. Much more research is needed to reliably gauge the overall effectiveness of these approaches, further address the nuances of burnout as it applies specifically to surgeons, and ensure that members of the surgical workforce remain at their peak throughout the duration of their careers.

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Introduction

Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.

Methods

We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.

Results

Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.

Conclusion

Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

The Physician's Physician: The Role of the Psychiatrist in Helping Other Physicians and Promoting Wellness

Psychiatrists have valuable training, knowledge, and experience to serve as champions for physician health. The prevalence of physician burnout, suicide, and depression negatively affects the health care system at a critical time when the country faces a physician shortage, increasing costs, and a push toward higher quality of care. Psychiatrists are in prime position to serve as the "Physician's Physician" and lead their organizations to increase awareness, build capacity, and drive cultural change. New leadership opportunities exist for psychiatrists, including the role of chief wellness officer, serving on physician well-being committees, and learning skills required to treat other physicians as patients.

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017

OBJECTIVE

To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and 2014.

PARTICIPANTS AND METHODS

Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools.

RESULTS

Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults.

CONCLUSION

Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.

Practicing Clinicians' Recommendations to Reduce Burden from the Electronic Health Record Inbox: a Mixed-Methods Study

BACKGROUND

Workload from electronic health record (EHR) inbox notifications leads to information overload and contributes to job dissatisfaction and physician burnout. Better understanding of physicians' inbox requirements and workflows could optimize inbox designs, enhance efficiency, and reduce safety risks from information overload.

DESIGN

We conducted a mixed-methods study to identify strategies to enhance EHR inbox design and workflow. First, we performed a secondary analysis of national survey data of all Department of Veterans Affairs (VA) primary care practitioners (PCP) to identify major themes in responses to a free-text question soliciting suggestions to improve EHR inbox design and workflows. We then conducted expert interviews of clinicians at five health care systems (1 VA and 4 non-VA settings using 4 different EHRs) to understand existing optimal strategies to improve efficiency and situational awareness related to EHR inbox use. Themes from survey data were cross-validated with interview findings.

RESULTS

We analyzed responses from 2104 PCPs who completed the free-text inbox question (of 5001 PCPs who responded to survey) and used an inductive approach to identify five themes: (1) Inbox notification content should be actionable for patient care and relevant to recipient clinician, (2) Inboxes should reduce risk of losing messages, (3) Inbox functionality should be optimized to improve efficiency of processing notifications, (4) Team support should be leveraged to help with EHR inbox notification burden, (5) Sufficient time should be provided to all clinicians to process EHR inbox notifications. We subsequently interviewed 15 VA and non-VA clinicians and identified 11 unique strategies, each corresponding directly with one of these five themes.

CONCLUSION

Feedback from practicing end-user clinicians provides robust evidence to improve content and design of the EHR inbox and related clinical workflows and organizational policies. Several strategies we identified could improve clinicians' EHR efficiency and satisfaction as well as empower them to work with their local administrators, health IT personnel, and EHR developers to improve these systems.

Function of the Medical Team Quarterback: Patient, Family, and Physician Perspectives on Team Care Coordination in Patient- and Family-Centered Primary Care

CONTEXT

Patient- and family-centered care (PFCC) literature is growing, but few reports present patient, caregiver, and practitioner perspectives about care coordination in a team-based model.

OBJECTIVE

To understand the patient's, caregiver's, and physician's ideal forms of PFCC, we investigated the function of the medical team quarterback, who coordinates and advocates for appropriate care, and probed to understand how the quarterback works with a team to contribute to ideal PFCC.

DESIGN AND MAIN OUTCOME MEASURES

Nine focus groups with 92 participants were held in 3 major cities. Patients (n = 35) and family members (n = 36) were recruited through market research groups. Physicians (n = 21) were recruited by the American College of Physicians. Focus group transcripts were analyzed and coded using inductive analysis.

RESULTS

The quarterback emerged as an important function for addressing care gaps and improving the care experience. We identified 6 themes articulated by participants that defined the role of a medical team quarterback: Overseeing care; coordinating diagnoses, tests, and treatments; advocating for patients; identifying and respecting patient values; proactively communicating; and solving problems. Patients and family members in our sample were open to different members of the care team acting as quarterback in coordination with the physician.

CONCLUSION

Medical team quarterbacks were perceived as enhancing team-based care by facilitating the coordination/communication that is critical to PFCC. Patients and family members acknowledged that PFCC can be delivered by different members of the medical team if the care felt organized and coordinated with the primary care physician.

How are medical students using the Electronic Health Record (EHR)?: An analysis of EHR use on an inpatient medicine rotation

Physicians currently spend as much as half of their day in front of the computer. The Electronic Health Record (EHR) has been associated with declining bedside skills and physician burnout. Medical student EHR use has not been well studied or characterized. However, student responsibilities for EHR documentation will likely increase as the Centers for Medicare and Medicaid Services (CMS) most recent provisions now allow student notes for billing which will likely increase the role of medical student use of the EHR over time. To gain a better understanding of how medical students use the EHR at our institution, we retrospectively analyzed 6,692,994 EHR interactions from 49 third-year clerkship medical students and their supervising physicians assigned to the inpatient medicine ward rotation between June 25 2015 and June 24 2016 at a tertiary academic medical center. Medical students spent 4.42 hours (37%) of each day at the on the EHR and 35 minutes logging in from home. Improved understanding of student EHR-use and the effects on well-being warrants further attention, especially as EHR use increases with early trainees.

Healing the Professional Culture of Medicine

The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.

Ten Ways Artificial Intelligence Will Transform Primary Care

Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.

Human Factors and Usability for Health Information Technology: Old and New Challenges

OBJECTIVES

Despite national mandates, incentives, and other programs, the design of health information technology (IT) remains problematic and usability problems continue to be reported. This paper reviews recent literature on human factors and usability of health IT, with a specific focus on research aimed at applying human factors methods and principles to improve the actual design of health IT, its use, and associated patient and clinician outcomes.

METHODS

We reviewed recent literature on human factors and usability problems of health IT and research on human-centered design of health IT for clinicians and patients.

RESULTS

Studies continue to show usability problems of health IT experienced by multiple groups of health care professionals (e.g., physicians and nurses) as well as patients. Recent research shows that usability is influenced by both designers (e.g., IT vendors) and implementers in health care organizations, and that the application of human-centered design practices needs to be further improved and extended. We welcome emerging research on the design of health IT for teams as team-based care is increasingly implemented throughout health care.

CONCLUSIONS

Progress in the application of human factors methods and principles to the design of health IT is occurring, with important information provided on their actual impact on care processes and patient outcomes. Future research should examine the work of health IT designers and implementers, which would help to develop strategies for further embedding human factors engineering in IT design processes.

Setting our sights on the right target: how addressing physician burnout may be a solution for improved patient experience

Physician burnout is an important issue that can have serious implications for both physicians and patients. Many of the techniques used by larger medical groups attempt to compel improvements in patient satisfaction scores at the potential cost of increased physician burnout. Because burnout has been associated with poorer patient care and experience, medical groups large and small should work aggressively to reduce the causes of burnout as a way to also improve patient experience. In this contribution, the patient experience measure and the electronic medical record are reviewed in the context of the regulatory and bureaucratic pressures they place on physicians to examine how they may contribute to burnout and, therefore, worsen patient experience.

Influence of Scribes on Patient-Physician Communication in Primary Care Encounters: Mixed Methods Study

BACKGROUND

With the increasing adoption of electronic health record (EHR) systems, documentation-related burdens have been increasing for health care providers. Recent estimates indicate that primary care providers spend about one-half of their workdays interacting with the EHR, of which about half is focused on clerical tasks. To reduce documentation burdens associated with the EHR, health care systems and physician practices are increasingly implementing medical scribes to assist providers with real-time documentation. Scribes are typically unlicensed paraprofessionals who assist health care providers by documenting notes electronically under the direction of a licensed practitioner or physician in real time. Despite the promise of scribes, few studies have investigated their effect on clinical encounters, particularly with regard to patient-provider communication.

OBJECTIVE

The purpose of this quasi-experimental pilot study was to understand how scribes affect patient-physician communication in primary care clinical encounters.

METHODS

We employed a convergent mixed methods design and included a sample of three physician-scribe pairs and 34 patients. Patients' clinical encounters were randomly assigned to a scribe or nonscribe group. We conducted patient surveys focused on perceptions of patient-provider communication and satisfaction with encounters, video recorded clinical encounters, and conducted physician interviews about their experiences with scribes.

RESULTS

Overall, the survey results revealed that patients across both arms reported very high satisfaction of communication with their physician, their physician's use of the EHR, and their care, with very little variability. Video recording analysis supported patient survey data by demonstrating high measures of communication among physicians in both scribed and nonscribed encounters. Furthermore, video recordings revealed that the presence of scribes had very little effect on the clinical encounter.

CONCLUSIONS

From the patient's perspective, scribes are an acceptable addition to clinical encounters. Although they do not have much impact on patients' perceptions of satisfaction and their impact on the clinical encounter itself was minimal, their potential to reduce documentation-related burden on physicians is valuable. Physicians noted important issues related to scribes, including important considerations for implementing scribe programs, the role of scribes in patient interactions, how physicians work with scribes, characteristics of good scribes, and the role of scribes in physician workflow.

Protecting healing relationships in the age of electronic health records: report from an international conference

We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.

Electronic health record (EHR) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR

OBJECTIVE

To understand if providers who had additional electronic health record (EHR) training improved their satisfaction, decreased personal EHR-use time, and decreased turnaround time on tasks.

MATERIALS AND METHODS

This pre-post study with no controls evaluated the impact of a supplemental EHR training program on a group of academic and community practice clinicians that previously had go-live group EHR training and 20 months experience using this EHR on self-reported data, calculated EHR time, and vendor-reported metrics.

RESULTS

Providers self-reported significant improvements in their knowledge of efficiency tools in the EHR after training and doubled (significant) their preference list entries (mean pre = 38.1 [65.88], post = 63.5 [90.47], P < .01). Of the 7 EHR satisfaction variables, only 1 self-reported variable significantly improved after training: Control over my workload in the EHR (mean pre = 2.7 [0.96], post = 3.0 [1.04], P < .01). There was no significant decrease in their calculated EHR usage outside of clinic (mean pre = 0.39 [0.77] to post = 0.37 [0.48], P = .73). No significant difference was seen in turnaround time for patient calls (mean pre = 2.3 [2.06] days, post = 1.9 [1.76] days, P = .08) and results (mean before = 4.0 [2.79] days, after = 3.2 [2.33] days, P = .03).

DISCUSSION

Multiple sources of data provide a holistic view of the provider experience in the EHR. This study suggests that individualized EHR training can improve the knowledge of EHR tools and satisfaction with their perceived control of EHR workload, however this did not translate into less Clinician Logged-In Outside Clinic (CLOC) time, a calculated metric, nor quicker turnaround on in box tasks. CLOC time emerged as a potential less-costly surrogate metric for provider satisfaction in EHR work than surveying clinicians. Further study is required to understand the cost-benefit of various interventions to decrease CLOC time.

CONCLUSIONS

This supplemental EHR training session, 20 months post go-live, where most participants elected to receive 2 or fewer sessions did significantly improve provider satisfaction with perceived control over their workload in the EHR, but it was not effective in decreasing EHR-use time outside of clinic. CLOC time, a calculated metric, could be a practical trackable surrogate for provider satisfaction (inverse correlation) with after-hours time spent in the EHR. Further study into interventions that decrease CLOC time and improve turnaround time to respond to inbox tasks are suggested next steps.

Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support

Primary care teams are underpowered. Teams do not maximally redistribute team functions when clinicians are diverted from activities where they add the most value. This commentary describes "advanced team care with in-room support" as a way to "power-up" primary care teams. In this core team model, each clinician is paired with 2 or 3 highly trained medical assistants or nurses-care team coordinators (CTCs).Early evidence suggests that this model is more satisfying to clinicians, staff, and patients and is financially sustainable. Yet its spread has been hobbled by several misguided beliefs, such as that the physician can and should do most tasks, that technology replaces people, that health care is a transactional endeavor more than a therapeutic relationship, that regulation is the main lever by which to advance quality, and that the principal way to increase net revenue is to reduce overhead. A shift in mindset is needed to energize primary care.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION

To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics.

METHODS

We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016.

RESULTS

Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics.

CONCLUSIONS

Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

The US health system has recently achieved widespread adoption of electronic health record (EHR) systems, primarily driven by financial incentives provided by the Meaningful Use (MU) program. Although successful in promoting EHR adoption and use, the program, and other contributing factors, also produced important unintended consequences (UCs) with far-reaching implications for the US health system. Based on our own experiences from large health information technology (HIT) adoption projects and a collection of key studies in HIT evaluation, we discuss the most prominent UCs of MU: failed expectations, EHR market saturation, innovation vacuum, physician burnout, and data obfuscation. We identify challenges resulting from these UCs and provide recommendations for future research to empower the broader medical and informatics communities to realize the full potential of a now digitized health system. We believe that fixing these unanticipated effects will demand efforts from diverse players such as health care providers, administrators, HIT vendors, policy makers, informatics researchers, funding agencies, and outside developers; promotion of new business models; collaboration between academic medical centers and informatics research departments; and improved methods for evaluations of HIT.

Changes in Electronic Health Record Use Time and Documentation over the Course of a Decade

PURPOSE

With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption.

DESIGN

Single-center cohort study.

PARTICIPANTS

Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers.

METHODS

We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models.

MAIN OUTCOME MEASURES

Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters.

RESULTS

Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010.

CONCLUSIONS

After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis

BACKGROUND

Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use.

OBJECTIVE

The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use.

METHODS

We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes.

RESULTS

Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use.

CONCLUSIONS

Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Establishing a Mutually Respectful Environment in the Workplace: A Toolbox for Performance Excellence

Most health care professionals spend a substantial amount of their time at the workplace. Our interactions with team members can define our daily experiences, impact our work performance, and influence our overall job satisfaction. Over the last years, how we interact with colleagues and patients has changed with the introduction of social media, a tenser political climate, and an evolving health care system. In oncology, a team can be composed of medical students, clinicians, and support and administrative staff within a heavy emotional environment where some of our patients are facing the risk of early mortality and most are dealing with the unmeasurable burden of cancer. Many of these factors can increase the risk for professionalism lapses. We discuss common challenges faced in the practice of cancer care, including the generational gap between medical trainees and senior members, gender disparities, and microaggressions. Microaggressions represent verbal, behavioral, and environmental indignities that communicate hostile, derogatory, and negative slights that insult a target person or group. Microaggressions should not be accepted as the norm in the workplace. It is essential to recognize these negative behaviors and manage them effectively to reduce or even prevent the long-term toxicities that these behaviors can bring to the workplace environment. Ultimately, we must acknowledge that these issues exist and remember that education and collaboration are the pillars of an inclusive workplace. We owe such efforts to our patients who deserve good care, to our partners in the care of patients so that they feel supported and included, and to ourselves.

Burnout and EHR use among academic primary care physicians with varied clinical workloads

Burnout is becoming increasingly prevalent among primary care physicians. Recent studies have attributed electronic health record (EHR) related tasks as a potential source of physician burnout. In this cross-sectional study, EHR use was compared to self-reported burnout for 107 faculty physicians at 10 university-affiliated primary care clinics. Physicians who self-reported burnout spent more time managing their inbox and in the EHR after hours. Burnout was associated with lower rates of same day chart closure, longer completion time for inbox messages, and more incomplete messages. Burnout, while related to overall workload, had a complex relationship with EHR use, which was influenced by but could not wholly explained by clinical workload. Our results suggest that burnout is less prevalent with less allocated clinical time, however, more research is necessary to identify the optimal balance between clinical duties and academic pursuits. Segmenting providers based on relative workload to determine variation within similar groups may help optimize EHR use.

Looking Behind the Curtain: Identifying Factors Contributing to Changes on Care Outcomes During a Large Commercial EHR Implementation

Objective:

To identify factors contributing to changes on quality, productivity, and safety outcomes during a large commercial electronic health record (EHR) implementation and to guide future research.

Methods:

We conducted a mixed-methods study assessing the impact of a commercial EHR implementation. The method consisted of a quantitative longitudinal evaluation followed by qualitative semi-structured, in-depth interviews with clinical employees from the same implementation. Fourteen interviews were recorded and transcribed. Three authors independently coded interview narratives and via consensus identified factors contributing to changes on 15 outcomes of quality, productivity, and safety.

Results:

We identified 14 factors that potentially affected the outcomes previously monitored. Our findings demonstrate that several factors related to the implementation (e.g., incomplete data migration), partially related (e.g., intentional decrease in volume of work), and not related (e.g., health insurance changes) may affect outcomes in different ways.

Discussion:

This is the first study to investigate factors contributing to changes on a broad set of quality, productivity, and safety outcomes during an EHR implementation guided by the results of a large longitudinal evaluation. The diversity of factors identified indicates that the need for organizational adaptation to take full advantage of new technologies is as important for health care as it is for other services sectors.

Conclusions:

We recommend continuous identification and monitoring of these factors in future evaluations to hopefully increase our understanding of the full impact of health information technology interventions.

Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level

Burnout has been implicated in higher physician turnover, reduced patient satisfaction, and worsened safety, but understanding the degree of burnout in a given physician or team does not direct leaders to solutions. The model proposed integrates a long list of variables that may ameliorate burnout into a prioritized, easy-to-understand hierarchy. Modified from Maslow's hierarchy, the model directs leaders to address physicians' basic physical and mental health needs first; patient and physician physical safety second; and then address higher-order needs, including respect from colleagues, patients, processes, and the electronic health record; appreciation and connection; and finally, time and resources to heal patients and contribute to the greater good. Assessments based on this model will help leaders prioritize interventions and improve physician wellness.

Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden

OBJECTIVE

To evaluate a novel clinic-focused Sprint process (an intensive team-based intervention) to optimize electronic health record (EHR) efficiency.

METHODS

An 11-member team including 1 project manager, 1 physician informaticist, 1 nurse informaticist, 4 EHR analysts, and 4 trainers worked in conjunction with clinic leaders to conduct on-site EHR and workflow optimization for 2 weeks. The Sprint intervention included clinician and staff EHR training, building specialty-specific EHR tools, and redesigning teamwork. We used Agile project management principles to prioritize and track optimization requests. We surveyed clinicians about EHR burden, satisfaction with EHR, teamwork, and burnout 60 days before and 2 weeks after Sprint. We describe the curriculum, pre-Sprint planning, survey instruments, daily schedule, and strategies for clinician engagement.

RESULTS

We report the results of Sprint in 6 clinics. With the use of the Net Promoter Score, clinician satisfaction with the EHR increased from -15 to +12 (-100 [worst] to +100 [best]). The Net Promoter Score for Sprint was +52. Perceptions of "We provide excellent care with the EHR," "Our clinic's use of the EHR has improved," and "Time spent charting" all improved. We report clinician satisfaction with specific Sprint activities. The percentage of clinicians endorsing burnout was 39% (47/119) before and 34% (37/107) after the intervention. Response rates to the survey questions were 47% (97/205) to 61% (89/145).

CONCLUSION

The EHR optimization Sprint is highly recommended by clinicians and improves teamwork and satisfaction with the EHR. Key members of the Sprint team as well as effective local clinic leaders are crucial to success.

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout—a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment—is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of “no mistakes allowed.” Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called “second victim” syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular.

Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians

IMPORTANCE

Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance.

OBJECTIVE

To assess the association between the usability of an EHR system for the management of abnormal test results and physicians' cognitive workload and performance levels.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018.

INTERVENTIONS

The EHR with enhanced usability segregated in a dedicated folder previously identified critical test results for patients who did not appear for a scheduled follow-up evaluation and provided policy-based decision support instructions for next steps. The baseline EHR displayed all patients with abnormal or critical test results in a general folder and provided no decision support instructions for next steps.

MAIN OUTCOMES AND MEASURES

Cognitive workload was quantified subjectively using NASA-Task Load Index and physiologically using blink rates. Performance was quantified according to the percentage of appropriately managed abnormal test results.

RESULTS

Of the 38 participants, 25 (66%) were female. The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate (mean [SD] blinks per minute, 16 [9] vs 24 [7]; blink rate, -8 [95% CI, -13 to -2]; P = .01). The baseline group showed statistically significantly poorer performance compared with the enhanced group who appropriately managed 16% more abnormal test results (mean [SD] performance, 68% [19%] vs 98% [18%]; performance rate, -30% [95% CI, -40% to -20%]; P < .001).

CONCLUSIONS AND RELEVANCE

Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non-value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.

Interprofessional Communication Goes Up When the Electronic Health Record Goes Down

OBJECTIVE

The electronic health record (EHR) has been faulted for the erosion of interprofessional communication and the patient-physician relationship. Surgical residents may be susceptible to communication workarounds facilitated by the EHR, but the full extent is not well understood. A recent ransomware attack with the abrupt return to paper charting provided a unique opportunity to investigate the impact of the EHR on surgical residents' interprofessional communication. We sought to explore how surgical residents perceived communications during the 2-month period when the EHR was inaccessible.

DESIGN

General surgery residents who rotated through the regional tertiary referral medical center and level I trauma center were invited to participate in a semistructured interview about communication with one another, faculty, staff, and patients during the downtime. A grounded theory approach was used to analyze the data.

SETTING

Regional tertiary referral medical center and level I trauma center.

PARTICIPANTS

General surgery residents who rotated through the affected site.

RESULTS

Ten general surgery residents were interviewed. Interviews revealed that the abrupt loss of the EHR impacted communication in three major ways: (1) engendered more professional courtesy and collegiality, (2) prioritized bedside patient care over documentation demands, and (3) encouraged more explicit and deliberate communications.

CONCLUSIONS

Our study demonstrates that the loss of the EHR encourages surgery residents interprofessional communication. With healthcare becoming increasingly digital, active efforts should be made to preserve the communication benefits by optimizing existing and emerging technology to facilitate direct face-to-face interactions.

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

Organizational factors affecting physician well-being

Purpose of review

Symptoms of burnout affect approximately half of pediatricians and pediatric subspecialists at any given time, with similarly concerning prevalence of other aspects of physician distress, including fatigue, depressive symptoms, and suicidal ideation. Physician well-being affects quality of care, patient satisfaction, and physician turnover. Organizational factors influence well-being, stressing the need for organizations to address this epidemic.

Recent findings

Organizational characteristics, policies, and culture influence physician well-being, and specific strategies may support an environment where physicians thrive. We highlight four organizational opportunities to improve physician well-being: developing leaders, cultivating community and organizational culture, improving practice efficiency, and optimizing administrative policies. Leaders play a key role in aligning organizational and individual values, promoting professional fulfillment, and fostering a culture of collegiality and social support among physicians. Reducing documentation burden and improving practice efficiency may help balance job demands and resources. Finally, reforming administrative policies may reduce work-home conflict, support physician's efforts to attend to their own well-being, and normalize use of supportive resources.

Summary

Physician well-being is critical to organizational success, sustainment of an adequate workforce, and optimal patient outcomes. Because burnout is primarily influenced by organizational factors, organizational interventions are key to promoting well-being. Developing supportive leadership, fostering a culture of wellness, optimizing practice efficiency, and improving administrative policies are worthy of organizational action and further research.

Characterizing electronic health record usage patterns of inpatient medicine residents using event log data

Amid growing rates of burnout, physicians report increasing electronic health record (EHR) usage alongside decreasing clinical facetime with patients. There exists a pressing need to improve physician-computer-patient interactions by streamlining EHR workflow. To identify interventions to improve EHR design and usage, we systematically characterize EHR activity among internal medicine residents at a tertiary academic hospital across various inpatient rotations and roles from June 2013 to November 2016. Logged EHR timestamps were extracted from Stanford Hospital’s EHR system (Epic) and cross-referenced against resident rotation schedules. We tracked the quantity of EHR logs across 24-hour cycles to reveal daily usage patterns. In addition, we decomposed daily EHR time into time spent on specific EHR actions (e.g. chart review, note entry and review, results review).In examining 24-hour usage cycles from general medicine day and night team rotations, we identified a prominent trend in which night team activity promptly ceased at the shift’s end, while day team activity tended to linger post-shift. Across all rotations and roles, residents spent on average 5.38 hours (standard deviation = 2.07) using the EHR. PGY1 (post-graduate year one) interns and PGY2+ residents spent on average 2.4 and 4.1 times the number of EHR hours on information review (chart, note, and results review) as information entry (note and order entry).Analysis of EHR event log data can enable medical educators and programs to develop more targeted interventions to improve physician-computer-patient interactions, centered on specific EHR actions.

The Science of Motivation Applied to Clinician Burnout: Lessons for Healthcare

The science of motivation can help explain some of the root causes driving clinician burnout, a critical vulnerability in healthcare today. Research finds autonomy, mastery, and purpose to be drivers of intrinsic motivation, and healthcare leaders can use these three principles in program design and communication strategies to make progress toward rediscovering joy and passion in the life-giving work of healthcare. Leaders can achieve a competitive advantage for their organizations by applying these inherent motivators to attract, develop, and retain engaged and purposeful caregivers and by developing participative leadership to nurture a passion for caregiving.In healthcare, we enjoy the privilege of serving with intelligent and caring people who are driven to make a difference on behalf of those they serve. But we also experience the human factors, friction, and uncertainty in a highly complex delivery and reimbursement structure. Each day in our hospitals, clinicians and staff face a marathon of adrenaline, stress, physical fatigue, mental strain, and emotional heights and depths. This reality demands grit and resilience to sustain the high standards of excellence and compassion necessary for delivering personalized care.Before healthcare organizations launch new programs to address these challenges, however, we must align our leadership and communication approaches with the fundamental drivers of motivation that brought us to healthcare in the first place-and in a way that brings out the best in our care teams and builds their creative capacity for any future challenges.

The elephant in the record: On the multiplicity of data recording work

This article focuses on the production side of clinical data work, or data recording work, and in particular, on its multiplicity in terms of data variability. We report the findings from two case studies aimed at assessing the multiplicity that can be observed when the same medical phenomenon is recorded by multiple competent experts, yet the recorded data enable the knowledgeable management of illness trajectories. Often framed in terms of the latent unreliability of medical data, and then treated as a problem to solve, we argue that practitioners in the health informatics field must gain a greater awareness of the natural variability of data inscribing work, assess it, and design solutions that allow actors on both sides of clinical data work, that is, the production and care, as well as the primary and secondary uses of data to aptly inform each other's practices.

Automatic Detection of Front-Line Clinician Hospital Shifts: A Novel Use of Electronic Health Record Timestamp Data

OBJECTIVE

Excess physician work hours contribute to burnout and medical errors. Self-report of work hours is burdensome and often inaccurate. We aimed to validate a method that automatically determines provider shift duration based on electronic health record (EHR) timestamps across multiple inpatient settings within a single institution.

METHODS

We developed an algorithm to calculate shift start and end times for inpatient providers based on EHR timestamps. We validated the algorithm based on overlap between calculated shifts and scheduled shifts. We then demonstrated a use case by calculating shifts for pediatric residents on inpatient rotations from July 1, 2015 through June 30, 2016, comparing hours worked and number of shifts by rotation and role.

RESULTS

We collected 6.3 × 10⁷ EHR timestamps for 144 residents on 771 inpatient rotations, yielding 14,678 EHR-calculated shifts. Validation on a subset of shifts demonstrated 100% shift match and 87.9 ± 0.3% overlap (mean ± standard error [SE]) with scheduled shifts. Senior residents functioning as front-line clinicians worked more hours per 4-week block (mean ± SE: 273.5 ± 1.7) than senior residents in supervisory roles (253 ± 2.3) and junior residents (241 ± 2.5). Junior residents worked more shifts per block (21 ± 0.1) than senior residents (18 ± 0.1).

CONCLUSION

Automatic calculation of inpatient provider work hours is feasible using EHR timestamps. An algorithm to assess provider work hours demonstrated criterion validity via comparison with scheduled shifts. Differences between junior and senior residents in calculated mean hours worked and number of shifts per 4-week block were also consistent with differences in scheduled shifts and duty-hour restrictions.